ICU Layout

1

• ICU Layout
• The intensive care unit should be easily
  accessible by departments from which patients are
  admitted and close to departments which share
  engineering services.
• It is desirable that critically ill patients are
  separated from those requiring coronary care or
  high dependency care where a quieter environment
  is often needed.
• It is possible to provide intensive care and high
  dependency care in the same unit so long as
  patients can be separated within the unit.
• However, the differing requirements of these
  patients may limit such flexibility.
• The floor sizes given below represent a minimum
  guide.

2

• Size
• Intensive care bed requirements depend on the
  activity of the hospital with additional beds
  required for regional specialties such as
  cardiothoracic surgery or neurosurgery.
• Small (lt6 beds) or very large (gt14 beds) units
  may be difficult to manage although larger units
  may be divided operationally and allow better
  concentration or resources.

3

• Patient areas
• Patient areas must provide unobstructed passage
  around the bed with a floor space of 20m2 per
  bed. Curtains or screens are required for
  privacy.
• Floors and ceilings must be constructed to
  support heavy equipment (some may weigh 1000 kg.)
• Doors must allow for passage of bulky equipment
  as well as wide beds.
• Every bed should have access to a was hand basin.
• The specification should include at least 1
  cubicle per 6 beds with 30m2 floor area for
  isolation. Air conditioning should allow for
  positive and negative pressure control in
  cubicles, temperature and humidity control.

4

• Services must include adequate electricity supply
  (at least 20 scokets per bed) with emergency
  back-up supply. Oxygen (3) medical air (2) and
  suction (2) outlets must be available for every
  bed.
• The bed areas should have natural daylight and
  patients and staff should ideally have an outside
  view.
• Communications systems include an adequate number
  of telephones to avoid all telephones being in
  use at once, intercom systems to allow bed to bed
  communication and a system to control entry to
  the department.
• Computer networks should enable communication
  with central hospital administration and
  laboratory system.
• Other areas
• Other areas include storage space (12m2 per bed),
  dirty utility (20m2), clean utility (10m2),
  Offices (45m2), doctors bedroom (15m2),
  laboratory (15m2), seminar room (30m2), cleaners
  room (10m2), staff rest room, locker room,
  toilets, relatives area, bedroom and interview
  room.

5

• ICU Staffing (Medical)
• Intensive care has evolved from the early success
  in simple mechanical ventilation of the lungs of
  polio victims to the present day where patients
  admitted to intensive care will usually have
  failure or dysfunction of one or more organs
  systems requiring mechanical support and
  monitoring.
• The intensive care unit should have dedicated
  consultant sessions allocated with additional
  allocation for management and audit activities.
• These sessions should be divided between several
  intensive care specialists.
• In addition, the intensive care specialist should
  be supported by junior doctors in training who
  can provide 24h per day cover on a rota which
  provides for adequate rest.

6

• Required skills of intensive care medical staff.
• Management
• Senior intensive care medical staff, together
  with their senior nursing colleagues, command the
  primary responsibility for the financial
  management of the intensive care unit.
• It is through their actions that treatment of the
  critically ill is initated and perpetuated they
  are ultimately responsible for the activity of
  the unit and patient out come.
• Decision making
• In the ICU most decisions are ultimately made by
  team consensus.
• Clinical decisions in the intensive care unit can
  be thought of under three categories
• i) Decisions relating to common or routine
  problems for which a unit policy exists
• ii) Decisions relating to uncommon problems
  requiring discussion with all ICU and non-ICU
  staff currently involved and.

7

• Decisions of an urgent nature taken by intensive
  care staff without delay.
• Practical skills
• Expertise in the management of complex equipment,
  monitoring procedures and performance of invasive
  procedures are required.
• Clinical experience
• Medical staff require experience in the
  recognition, prevention and management of
  critical illness, infection control, anesthesia
  and organ support.

8

• Technical knowledge
• The intensive care specialist has an important
  role in the choice of equipment used in the
  intensive care unit.
• Pharmacological knowledge
• drug therapy regimens are clearly open to the
  problems of drug interactions and, in addition,
  pharmacokinetics are often severely altered by
  the effects of major organs system dysfunction,
  particularly involving the liver and kidneys.
• Teaching and training
• The modern intensive care specialist has acquired
  a number of skills that cannot be gained outside
  the intensive care unit. It is therefore
  necessary to be able to provide this education to
  junior doctors in tainting for intensive care.

9

• ICU staffing (nursing)
• Critically ill patients require close nursing
  supervision. Many will require 11 nursing
  throughout a 24h period while other are of a
  lower dependency and can share nurses.
• A few patients are so ill with the need for
  multiple interventions that their real nursing
  requirement is gt11.
• In addition to the bedside nurses, the department
  needs additional staff to manage the day to day
  operation of the unit, to assist in lifting and
  handling of patients, to relieve bedside nurses
  for rest period and to collect drugs and
  equipment.
• These additional nurses can be termed the fixed
  nursing establishment and the nature of their
  duties is such that they will usually be higher
  grade nurses.
• The bedside nurses are a variable establishment
  and their numbers are dependent on activity such
  that more patients require higher numbers.
• Most departments fix their variable establishment
  by assuming an average activity.

10

• Fixed establishment
• In the UK providing 1 nurse per shift for 24h
  per day 7 days per week requires 4.5 nurses.
• In addition, staff , leave, study leave and
  sickness are usually calculated at 22 such that
  1 additional nurse is required.
• Thus the provision of 1 nurse in charge of each
  shift and 1 nurse to support the bedside nurses
  requires 11 additional nurses. In larger units
  there may be a need for additional support nurses
  and less in smaller units.
• Variable establishment
• The same principles apply for the provision of
  bedside nurses.
• Thus, to provide 11 nursing for a bed requires
  5.5 nurses and to provide 12 nursing requires
  2.75 nurses.
• The total number required depends on the
  occupancy and the nurse to patient ratio for each
  occupied bed.
• One of the difficulties in staffing an intensive
  care unit relates to the variable dependency and
  occupancy.

11

• An average dependency weighted occupancy (average
  occupancy x average nurse to patient ratio)
  should be used to set the establishment of
  bedside nurses with additional nurses being
  drafted in from a bank or agency to cover peak
  demands.
• Skill Mix
• Nursing skill mix is the subject of much
  controversy as the need for economy is balanced
  against the need for quality.
• As stated above the fixed nursing will usually be
  of higher grade since the role incorporates the
  administration of the unit and supervisory
  nursing.
• The bedside nurses will be made up of those who
  have received post qualification training in
  intensive care and those who have not.
• The ratio of trained to untrained intensive care
  nurses should be of the order of 31 of
  facilitate in service teaching.

12

• Medicolegal aspects
• The intensive care unit is a source of many
  medicolegal problems. Patients are often not
  competent to consent to treatment.
• They may be admitted following trauma, violence
  or poisoning, all of which may involve a legal
  process. Admission may also follow complications
  of treatment of medical mishaps occurring
  elsewhere n the hospital.
• The nature of critical illness is such that
  complication are common and litigation may
  follow.

13

• Consent
• Many procedures in intensive care are invasive or
  involve significant risk.
• The patient is often not competent to consent for
  such treatment such that the next of kin must be
  involved.
• It is essential that the risks and benefits are
  explained to the person giving assent and a
  chance is given for the patients wishes to be
  taken into account.
• It is all too easy to achieve assent from a
  relative without giving adequate explanation of
  the option.
• Research present consent problems in the
  critically ill and requires close ethical
  committee supervision.

14

• Note keeping
• It is impossible to record everything that
  happens in intensive care in the patients notes.
  
• The 24h observation chart provides that most
  detailed record of what has happened but summary
  notes are essential.
• Such notes must be factual without
  unsubstantiated opinions about the patient or
  about previous treatment .
• All entries must be timed and signed.
• Records of ward rounds must record the name of
  the consultant leading the round.
• It must be remembered that the notes may be used
  later in legal proceedings.
• They may be used against you but if well kept
  will usually form the best defence.
• In the event of a medical mishap the episode
  should be clearly documented after witnessed
  explanation to relatives.

15

• Dealing with the police
• Most police enquiries relate to patients who are
  admitted after suspicious circumstances.
• While there is a duty to patient confidentiality
  it may be in the patients interests to impart
  information about them.
• This may be with the consent of the patient or
  the next of kin.
• Written statements or verbal information may be
  requested.
• Any information given should avoid opinion and
  stick to facts.

16

• Dealing with the jurist
• The Corner must be informed of any death where as
  death certificate cannot be issued.
• Death certificate can be issued where the death
  is due to a natural cause and the patient has
  been seen professionally by the doctor within 14
  days prior to death.
• The table documents the conditions requiring the
  coroner to be informed. Where there is any doubt
  the corner should be informed.

17

• Deaths which must be informed to the jurist
• Unidentified body
• No doctor attending within prior 14 days
• Death without recovery from anesthesia
• Sudden or unexplained death
• Medical mishap
• Industrial accident or disease
• Violence, accident or misadventure
• Suspicious circumstances.
• Alcoholism
• Poisoning
• Death in custody